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February 10, 2016
Reality Training: Between a knife and a hard place
By David Neubert
What happened: You are en route to the trauma hospital with a patient stabbed in the chest. The trauma facility has the capability to perform open thoracotomy. You have a less than 10-minute ETA when he goes into cardiac arrest.
Discussion questions: Traumatic cardiac arrest care
1. What are the immediate resuscitative steps that should be taken when the patient arrests?
2. Which of these treatments is most appropriate? Why?
3. Do you begin chest compressions? If yes, do you remove the knife or leave it in place?
4. How would portable ultrasound in the ambulance be of assistance in determining resuscitative steps?
Removal of the knife is an absolute last resort, as it likely could contribute to further exsanguinating hemorrhage.
We typically do not treat hemorrhagic hypovolemic shock with fluid boluses, but since most prehospital systems do not have blood products, fluids wide open would be warranted in an attempt to increase pre-load. However, stop fluid administration as soon as signs of perfusion returned.
Consider a dose of epinephrine with the fluids to help combat severe shock. Administration of epinephrine leads to peripheral vasoconstriction and an increase in cardiac rate and contractility. It’s robbing Peter to pay Paul, but this might be enough to get the patient to definitive care, which is a thoracotomy.
This patient needs immediate bilateral chest decompression to address the possibility of tension pneumothorax. If trained and authorized the patient also needs a pericardiocentesis to reverse cardiac tamponade.
Certainly a quick cardiac rhythm check is in order, though the likelihood of an arrhythmia is lower than pulseless electrical activity or asystole. A defibrillation shock can be administered with the knife in place as long as you are not touching the knife. Remember, we shock patients with pacers in their chest.
Portable ultrasound would be very helpful. A FAST exam, which is a focused abdominal scan for trauma, would allow for visualization of the heart, scanning for pericardial effusion, and identification of blood that has entered the abdominal cavity suggestive of solid organ or abdominal great vessel injury.
Further ultrasound evaluation could determine where the tip of the knife lays, view lung fields for residual pneumothorax, directly visualize the aorta for injury, and check for pre-load and fluid status by seeing if the inferior vena cava is dilated or collapsed. All of these findings would directly impact the patient's treatment course.
Anoxic brain injury occurs with absent perfusion after four to six minutes. If the above interventions have not been successful, one cannot withhold care from someone that was just alive. You cannot reasonably do compressions with the knife in place. Even if you shield yourself from harm or stabilize the knife externally, compressions will cause additional internal lacerations and worsen whatever has been cut inside.
If the knife is in a great vessel and you remove it, it’s likely a death sentence. However, severing of a great vessel is nearly always a death sentence. If the ventricle was punctured, it is possible that if you remove the knife, the thick muscle layer and your compressions could slow further exsanguination. This would at least allow for some circulation of the blood and perfusion of brain tissue till thoracotomy repairs this wound in the trauma bay.
It’s a judgment call, and not an easy one, which is why this case is offered for discussion. Others may have differing opinions on removal of the knife. There are no right answers to the knife removal question, but now is the time to consider the care steps you would take should you ever have a patient such as this one.
Learn more about penetrating chest trauma:
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